If you’ve been following the tumblr meme of sites that use photos of Ryan Gosling with “Hey girl” sayings, it’s excitably reached the birth activist world.

Homebirth Ryan Gosling shows us all sorts of approving statements about homebirth from America’s heart throb. One part poking fun at the birth activist community and one part legitimate support for homebirth, it’s worth checking out.

After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.

There are many reasons for this increase, from Ricki Lake and the Business of Being Born, to studies that show serious problems with our maternal and fetal mortality rate. Also midwifery is on the rise, and CPMs have been successfully pushing for recognition at the state level.

To those of us who support the midwifery model of care and believe that leaving the hospital setting is a good idea for many low-risk births, this is great news. It’s also still disappointing that the overall percentage is so low–less than 1% of all births! Although when you look at it on a state level, there are places (like Montana and Oregon) where the rates are double the national average.

But, as we’ve come to expect, when you examine these numbers based on race and ethnicity, the picture is very different:

For non-Hispanic white women, home births increased by 36%, from 0.80% in 2004 to 1.09% in 2009. About 1 in every 90 births for non-Hispanic white women is now a home birth. Home births are less common among women of other racial or ethnic groups.

About 90% of the total increase in home births from 2004 to 2009 was due to the increase among non-Hispanic white women.

The chart above shows just how dramatic the disparity is. I addressed some of my thoughts about what’s behind this gap in this post, which generated some good discussion in the comment thread.

I think we’ll see that racial gap diminish when midwifery advocates include people of color in their work. When more midwives and doulas of color are leading these initiatives, and also when public funding for out-of-hospital birth care is addressed.

The other disparity that the CDC study points out is a geographic one, which may also mirror the racial disparities:

The percentage of home births was generally higher in the northwestern and lower in the southeastern United States.

This Northern/Southern disparity is true for many health outcomes, and can probably be attributed to demographic differences, as well as a political climate that more favors midwifery and out of hospital birth in the Northwest. It’s clear we need more strong midwifery advocates in the South–and that would also be a place where it would make sense for people of color to take the helm.

We know that a shift as radical as bringing maternity back out of the hospital is going to take decades. It was a decades-long,  well-funded campaign that brought birth into the purview of doctors and hospitals to begin with. The good news is we are moving in the right direction, but if we leave women of color behind, we’re not going to achieve the wide-spread culture shift we’re working towards.

In New America Media, Valeria Fernandez writes about efforts to revive Mexican midwifery in Arizona:

Marinah Valenzuela Farrell is one of only a few licensed midwives in Arizona. Though it isn’t a profitable venture, helping mothers bring their newborn children into this world is for Farrell a calling deeply rooted in her native Mexican tradition.

“It is really hard to be a midwife,” said the 41-year-old. “You don’t sleep, and you don’t make money. People think you’re crazy because you’re doing homebirths.”

A majority of Farrell’s clients are middle class and white, though as a Latina she aims to make midwifery accessible to low-income women in dire need of prenatal services but too afraid to seek them out in a state virulently hostile to undocumented immigrants.

“I think they don’t know that we exist,” she said. “I think the more the community knows that there’s a midwife who will come and visit them at home and do a homebirth… [attitudes] will change and shift.”

I spoke to the author while she was working on the piece, and a quote of mine is included toward the end.

In The Grio, Chika Oduah writes about black women and home birth. The article includes a video, which is a good primer of the issues at hand with home birth. It also references my Colorlines article about the possible connection between maternal health in communities of color and access to midwifery care.

What is clear from the research about this issue is that women of color are less likely to receive midwifery care, and that disparity is larger than the population numbers would suggest. I think this dynamic is complicated by global sociopolitical historical factors. For example I experienced resistance from Latina immigrant women to midwifery care because of the stigma toward parteras (midwives) in their home countries. In many places in Latin America, midwives and home birth are seen as the option used by women who can’t afford to go to hospital for birth–basically an option only for those who have no other option.

That creates class and race stigma on home birth and midwifery care.

This stigma is no accident. Global socioeconomic policy in Latin America (and I assume elsewhere as well) has long promoted hospital-based childbirth as a marker of development, and encouraged this move with foreign aid dollars and other development initiatives. The medical students I observed in Ecuador were clear that their obstetrical training and guidance came from US practice. So does the push toward hospital-based birth and away from traditional midwifery care.

We cannot ignore the fact that lack of access to emergency obstetrical care and trained birth attendants does lead to increased maternal and infant mortality. But we must also acknowledge what is lost and what new risks emerge when the model is pushed wholly toward medicalized hospital based care. Example: the United States. 98% of births happen in hospitals in the US, but our maternal and infant mortality rates are a serious concern, and lag behind 48 other countries. Clearly simply moving birth from home to hospital does not solve infant or maternal mortality.

I digress a bit, but the ultimate point is this stigma comes with immigrant women, and influences the choices they might make when it comes to maternity care in the US.

With African American folks who might not be recent immigrants, there is another factor at play. Claudia Booker was the first to make this connection for me. When hospital birth first began in the US, and for quite some time after, black women were excluded because of racism and classism. Those barriers to receiving care in the hospital created a similar race and class stigma to that I described from Latin America–meaning that women of color might also see midwifery or home birth as the thing you do when you have no other option. Hospitals are the place that people with wealth and privilege go to give birth. Why would one then choose to opt out?

When we talk about midwifery care (and doula care for that matter) needing to be accessible to communities of color–we’re not just talking about Medicaid reimbursement or even language access. It’s a much more complicated sociopolitical history that must be understood. We have to remember and learn how racism has impacted the way we give birth, the options we have, and understand the ways in which that history affects our choices today.

I often feel like discussions of the need to “educate” certain populations are condescending. It implies that we hold knowledge that the other group does not–that we know better than they do what is best for them. Really I think this kind of accessibility will be gained by listening, rather than teaching or educating. By asking the people we seek to reach what keeps them from working with us, what shapes their decisions, and then adjusting our practice accordingly.

In reality, and this is what these articles get at, what will really change the number of people of color using midwifery–it will be midwives of color. Often those from the community themselves are the best advocates and have the cultural competency necessary to serve the community effectively.

Update: Native communities and their history was very absent from this post. In that vein I’m adding a link to this guest post, Why doulas are important in Native American Communities, from Raeanne Madison, which provides some context.

It’s a scary time for women’s health and autonomy. The political movement to limit access to abortion, as well as pregnant people’s rights to make decisions about their bodies and medical choices, is stronger than ever.

In the absence of any strategies to address the actual problems plaguing our economy (unemployment, for example) the ultra right wing in control of many of our state governments (and the House of Reps too) have decided to focus instead on debilitating budget cuts and bills that damage women and pregnant people’s health and human rights.

As I’ve said over and over on this blog–bills that limit access to abortion also limit the choices of pregnant people who want to parent. NAPW has a video explaining exactly what is at stake with Prop 26:

Irin Carmon, reporting for Salon, wrote about how this initiative would limit access to even birth control. These efforts are serious, and want to turn back the clock on reproductive health almost fifty years. All of these extreme efforts are poised to take judicial challenges all the way to the Supreme Court.

The vote on the initiative could go either way, which is even more frightening. Polling shows voters split evenly.

If you’re in Mississippi, please make it out to the polls tomorrow and vote NO on 26. This is serious.

From the Governor’s veto message:

At first blush, I was inclined to sign this bill because it certainly seems inapprpriate to shackle a pregnant inmate unless absolutely necessary. Hovwever, the language of this measure goes too far, prhohibiting no only hsackling, but also the use of handcuffs or restraints of any kind except under ill-defined circumstances.

Let’s be clear. Inmates, whether pregnant or not, need to be transported in a manner that is safe for them and others. The restrictive criteria set forth in this bill go beyond what is necessary to protect the health and dignity or pregnant inmates and will only serve to sow confusion and invite lawsuits.

This is really disappointing news, and further proof that the health and safety of pregnant incarcerated women is not a priority. The fact that he attempted to say that the use of handcuffs or restraints could actually be needed to “be transported in a manner that is safe for them” is appalling.

In my article for Colorlines last week, I talked to Marianne Bullock, a prison doula and co-founder of the Prison Birth Project. She had this to say about the danger of restraints during transport:

Marianne Bullock, cofounder of the Massachusetts-based Prison Birth Project, offers an anecdote from across the country illustrating why shackling during transport is an acute problem. As a doula who has been working within a Springfield prison for the last four years, Bullock and the other members of the Prison Birth Project see exactly how incarcerated pregnant women are treated. Even though their facility doesn’t shackle women during childbirth, shackles are still used during transport, especially postpartum. Bullock recounts one woman that she supported during labor who ended up with a full episiotomy (an incision to widen the vaginal opening) to deal with her baby’s shoulder dystocia.

“Twenty-four hours later she was shackled foot-to-foot and walked out of the hospital,” she remembered. “It’s so dangerous to have a woman walking shackled, with who knows how many stitches.”

Congrats to everyone in California for such an impressive push getting this bill through, and here is to hoping that it gets through next time.

Rebecca Brodie sits in her suburban Massachusetts home, talking on the phone with me while her family member sits nearby, filming the interview. The oldest female correctional facility in the United States, MCI-Framingham, is just a short eight-minute drive away. “When I conceived my third child earlier this year, it really hit home for me because everywhere I go I pass the prison,” Brodie explained. “I have all these choices and opportunities: who do I want in the room with me, do I want a water birth, or a home birth? Obviously the incarcerated women can’t make these choices.”

The proximity of the women’s prison and Brodie’s pro-bono legal work with incarcerated women is what inspired the protest she’s planning for December, when her third child is born. If all goes according to plan, she’ll be laboring and delivering her baby in metal restraints that restrict her arms and legs. She’s planning to simulate the same conditions that many incarcerated pregnant women face when delivering in state prisons and jails, including some of the women housed at the prison right by her home.

I’m still not sure what I think about Brodie’s plans. It’s an extreme form of protest, one that involves much spectacle (and a documentary to boot). But what it was clear everyone I talked to cares about the most is bringing attention to this horrific practice in hopes of ending it.

Only 14 states specifically ban the practice, and even those states don’t necessarily ban the use of shackles during transport. Governor Brown in California has a bill waiting on his desk for signature that would ban the practice during transport as well. The more work I do in the field of social justice the more I believe that the practices of our criminal justice system are some of the most dire issues we face today. We incarcerate more people than any other country in the world, and the treatment of people on the inside brings up many, many human rights questions.

I’m glad I was able to talk to one of the founders of volunteer doula program that I seriously admire, Marianne Bullock from the Prison Birth Project, for this article. Marianne and the other PBP folks work at a prison in Massachusetts, trying to address the myriad challenges moms on the inside face, including shackling.

Read the full article here.

But this was too good not to post! Erykah Badu, who has been a doula for years, is now training to become a midwife.

This is was the best part:

Badu, who provides all of her services for free, has since become a spokeswoman for the International Center for Traditional Childbearing and she is now aiming to get her professional certification so she can open birthing centres in inner cities in the future.

She reveals patients call her “Erykah Badoula” and insists “nothing gives me more pleasure” than assisting in anaesthesia-free births.

Erykah Badoula! Love it.

Via Toronto Sun

The New York Times reported that although home births still represent a small majority of overall deliveries, by the 2008 numbers they are up 20% since 2004. I’m sure we will see an even bigger increase once we get 2011 numbers.

This demonstrates that people are really getting the message that there are safe and viable alternatives to hospital birth.

You can share your home birth story in their comments section.

I often use the example of bowel movements when talking about why it makes little sense that women are forced to labor on their backs. Imagine taking a s–t lying down?! I say for emphasis. (Gravity, of course, is the missing element).

Well this new short film from the folks at the Future of Birth demonstrates how that analogy goes even further.

“Failure to progress” is one of the more common reasons cited for c-sections. It’s a vague diagnosis, and one based on a time table for birth that is overly standardized and limited. Pressure to progress, coupled with hospital environments that don’t encourage relaxation (think lots of staff in and out, harsh lights and machinery) can have serious impacts on the labor itself.

I’ve seen this first hand with women whose labor is progressing fine at home, but once they get to the hospital, survive the intake process and are settled into a room, stop having contractions altogether. What follows is usually lots of interventions and often a c-section.

We need to challenge these practices and highlight how they themselves interrupt the flow and progression of birth.

Ina May graciously allowed me to post the full text of our interview since only a few snippets made it into the Colorlines piece. She had a lot of wisdom about this issue (not surprisingly!). It really is worth the read–Ina May displays a really comprehensive understanding of the issues facing women of color when it comes to out-of-hospital birth care.

Here’s Ina May:

RD: You mention briefly in Birth Matters that when obstetricians were trying to bring birth to the hospital (and learn how to care for birth), one doctor in Chicago paid immigrant women to give birth there. I’ve also understood that initially, particularly black women weren’t allowed access to hospital birth because of segregation/racism and class issues as well.

IM: That’s true. In general, low-income women in urban areas were initially brought into hospitals so that doctors in training could practice on them. That how they “paid” for their care.

RD: Can you tell me a little more about the history of particularly women of color in the US when it came to birthing in the hospital? Did they have a different experience than white women in terms of when they made the transition from home birth to hospital birth?

IM: Yes. For the most part, women of color who lived in the rural south didn’t go into the hospital until the 1970s and 80s. Alabama, Mississippi, Arkansas, Florida, and Georgia still had midwives who assisted women giving birth at home right through the 1970s. When doctors could count on Medicaid reimbursement for the first time, that situation quickly changed, and the midwives who were so needed before were forced to retire. Farther north, the pattern was somewhat different, because midwifery was outlawed in many states. Everyone was pushed into the hospital when this happened, regardless of the color of their skin. Women of color and poor white women were both used as teaching material in the teaching hospitals throughout the country. For this reason, the shift from home birth to hospital birth took place much earlier among urban women of color than it did for those in rural areas of the south.

RD: Tell me about what you know about the demographics of women currently giving birth out of hospital with midwives. Are women of color accessing these services? If not, why do you think this is?

IM: A growing number of women of color are accessing these services, and I believe that many more would, who currently lack access to home birth services. I am sure that we’ll see more people gain access if the House Bill put forward by Chellie Pingree early this year becomes law [Edits made to reflect factual corrections about legislation sponsors]. This bill will include Certified Professional Midwives (CPMs) as Medicaid providers. Currently, birth centers which are staffed by CPMs are not able to open their doors to women with Medicaid coverage. I do know quite a few people who have visions of opening birth centers in urban areas with large populations of women of color. If the CPM bill passes, I think that we will see a great change, because many young women of color would like to be able to enjoy birth choices that include having a midwife-assisted birth, laboring in water and that kind of thing.

Lack of choice in maternity care is a major burden for women of color. In Los Angeles, for instance, going through MediCal means that you can count on getting an obstetrician instead of a midwife, and you’ll get the bare minimum of services. The obstetricians themselves are reimbursed so little by Medi-Cal that the moms get the worst care available. Informed choice is not part of the program. Each woman is expected to take the one choice that’s on the menu without complaint.

Another burden comes under the heading of required testing. Low-income women getting their care via Medi-Cal, for instance, are often told that they’ll have to be x-rayed for tuberculosis while pregnant.

Another problem is that CNMs of color in many areas of the country have a lot of trouble finding work. I can’t count the number who have told me that they are unable to get jobs at hospitals or birth centers, and it can be just as hard to find a doctor who will provide backup for home births.

RD: There has been a focus on the issue of low-birth weight and fetal mortality among particularly black and Latina women (for example, Healthy Start). Those programs have focused mostly on home visiting and case management to ensure that women get access to prenatal care and get enrolled in insurance programs.

Do you see a relationship between these negative outcomes and the dominance of hospital birth?

IM: Absolutely. Amnesty International’s publication, Deadly Delivery, has documented how difficult it is for women of color in many areas of the country to get into prenatal care early during pregnancy. This means that pregnancy complications are often missed in early stages when they could be turned around or prevented in the first place. It is also very clear that the kind of prenatal care that focuses on empowerment and education about healthy choices to make during pregnancy is central to preventing premature births and low-birth weight babies. Obstetricians don’t have the time or the training to provide the kind of care that actually prevents prematurity and low-birthweight. Countries that make more use of midwives (the countries with the lowest rates of newborn and maternal mortality make sure that in about 70% of births, the dominant caregiver is a midwife. It is she who provides the prenatal care and it is she who attends the birth, not an obstetrician. These countries understand that prevention of problems makes more sense than continuing to perpetuate the myth that every pregnancy and birth is a disaster waiting to happen. Prevention of complications depends upon helping women in early pregnancy to get good nutrition and exercise, and it also has to do with helping women reduce the stress in their lives.

RD: Do you think expanding access to midwifery care via CPM coverage in Medicaid could have an impact on these rates for women of color?

IM: I do. If CPMs could be reimbursed by Medicaid, more women of color could get into prenatal care early during pregnancy. CPMs aren’t under institutional constraints to do 10- or 15-minute prenatal visits. It takes time to provide the kind of counseling about nutrition and exercise that can prevent complications such as prematurity and low-birthweight.

It’s not just complications during pregnancy and labor that need to be prevented. Postpartum care after hospital discharge is very scanty in the US, except for that offered by homebirth midwives. It used to be that women were kept in hospital for five days after giving birth because of the possibility of postpartum hemorrhage, pulmonary embolism, or postpartum infection. Since the early 1990s, women have been discharged early from hospital. Even women who have had cesareans are often discharged on the 4th day or so after birth. This can be a safe practice, as long as there is a system of postpartum home visits that are organized specifically to make sure that mothers who could be in danger are diagnosed and treated before a problem becomes life-threatening. Most western European countries make sure that women get postpartum home visits during the ten days or so following birth by specially trained nurses or midwives—the kind of care that is routinely provided by home birth midwives, whether they are CNMs, CPMs, or CMs. However, most hospital-based practices do not provide such home visits, and in many cases, a phone call is all that a new mother might get during the first week or so after discharge.

I know of at least two cases in which single mothers (they were both women of color) died at home of postpartum hemorrhage after hospital discharge. (Tameka McFarquhar and Virginia Njoroge’s stories can both be found by clicking on “Virtual Quilt” at the Safe Motherhood Quilt Project website www.rememberthemothers.org. At least one of these women had what was supposedly decent insurance coverage, but it still didn’t provide for a home visit after hospital discharge, even though it was known that she was single and had no family members available to help her.

It’s not unusual for some bits of placenta or membrane to be left inside a mother after the placenta is delivered (usually when it removed manually, or sooner than it wants to come out on its own), and these women are in danger of a late postpartum hemorrhage if this situation is not detected. Ideally, placentas are carefully inspected for completeness just after they come out, but often this important step is neglected in hospitals where the assembly line runs fast. Midwives and postpartum nurses can diagnose this problem by smell or by touch, but a phone call to a new mother is not sufficient.

Other problems that may emerge after hospital discharge are infection or pulmonary embolism (particularly in women who have had cesareans). Both can be fatal. If women aren’t told of the symptoms of these conditions (I’m told that the discharge information is more likely to focus on providing birth control information), they may ignore symptoms and assume that leg pain is nothing to worry about (when it is, because it is a symptom of deep vein thrombosis that can lead to a pulmonary embolism).

All this said, I worry that if we, with all good intentions, decided to provide routine postpartum home visits to all mothers (not just those who have home births), such care could degenerate into another way to putting pressure on women of color by threatening them with losing custody of their babies. We have to find a way to provide postpartum for women that is nurturing and get away from the mode that we see too often that expects them to be perfect without education and constantly threatens them with punishment without providing the least support.

RD: Do you think there are particular barriers to encouraging women of color to consider midwifery care out of hospital that might different than for white women?

IM: I know that a generation ago, there was a perception among many women of color that midwife care was somehow second best—that it was associated with poverty. For a while now, I have been noticing that many women of color have wised up about this. I’m meeting many who are doulas, childbirth educators, and lactation consultants, and they tell me there is a huge demand for their services. They tell me that the young women that come to their classes are aware that water birth is a possibility and aware that breastfeeding is better for their babies than formula feeding. They’ve seen “The Business of Being Born” and “Orgasmic Birth” and “Birth Day” and want that kind of midwifery care too. The trouble is that these choices are not part of the standard package that is available to low-income women of color.

Despite what I mentioned above about a growing awareness of the value of midwifery care and the choices that midwifery-led care includes among women of color, there is still a lack of understanding of what a midwife does, and there is just as much fear of giving birth without medication among women of color as there is among Caucasian women. This fear obviously keeps many women from choosing out-of-hospital birth.

RD: In my work with immigrant women, particularly from Latin America, I’ve noticed that they bring with them the idea the home birth is what women who can’t afford to go to a hospital do. Have you noticed this bias among immigrant women toward hospitals? If so, how do you think this could be addressed by midwives and advocates?

IM: There is quite a lot of pressure on immigrant women to fit in and do things the way that most US women appear to be doing them. Part of this is probably because so few US women actually do give birth at home that immigrant women are barely aware that such services are available. Hospitals are able to provide interpreters for women whose languages aren’t spoken by midwives who provide out-of-hospital services. On the other hand, I do know that Muslim women in Dearborn, Michigan, do access home birth services in many cases. The Morris Heights Birth Center in NYC is another example of an out-of-hospital maternity service that provides access to immigrant women.

All this could change at a faster rate if the CPM bill passes.

RD: There is a really compelling argument for out-hospital birth in terms of cost saving. Why do you think this argument hasn’t been very effective for changing policy or practice when it comes to birth in the US?

IM: Cost-saving actually means very little in the organization of US maternity care. What we do here is to narrow the choices that women have while providing a very expensive form of care—one that often creates problems that then must be addressed. US maternity care is more focused on generating income for hospitals than it is on achieving the best possible birth outcomes for mothers and babies. If we were more focused on safety, there would be some limits placed on what fertility specialists are allowed to do here, since the multiple gestational pregnancies that have become so popular create many more risks for these mothers and their babies. If we were focused on safety and not just the appearance of it, we would already have turned over the care of healthy women to midwives. The evidence has been there for years, but the obstetrical profession in this country built itself on eradicating midwifery and it’s hard to turn this kind of situation around. It’s possible, but it’s hard.

Profits are maximized when caring midwives are replaced by electronic fetal monitors. Profits are maximized even as cesarean and induction rates rise. I’d like to see us junk this profit-based system and replace it with one that prioritizes mothers’ and babies’ best interests. That’s the only way I see us turning around the obscenely high rates of c-section, inducted labors, and maternal deaths that we have in this country